ITB: Purchase of Utility Vehicle

Attachment I: Debarment Certification Form
DEBARMENT CERTIFICATION FORM The Contractor certifies that, neither the Contractor firm nor
any owner, partner, director, officer, or principal of the Contractor, nor any person in a position with
management responsibility or responsibility for the administration of federal funds, nor any
subcontractors or suppliers:
(a) Are presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily
excluded from covered transactions by any federal or state department/agency:
(b) Have within a three-year period preceding this certification been convicted of or had a civil judgment
rendered against it for: commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public transaction or contract (federal, state, or local); violation of
federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(c) Are presently indicted for or otherwise criminally or civilly charged by a governmental entity (federal,
state, or local) with commission of any of the offenses enumerated in paragraph (b) above; or
(d) Have within a three-year period preceding this certification had one or more public transactions or
contracts (federal, state, or local) terminated for cause or default.
(e) The contractor is "Actively" registered with SAMS (Service for Award Management) and has been
assigned the following Unique Entity Identification Number: .
The Contractor further certifies that it shall not knowingly enter into any transaction with any
subcontractor, material supplier, or vendor who is debarred, suspended, declared ineligible, or voluntarily
excluded from covered transactions by any federal or state department/agency.
Dated this day of , 20
By
Authorized Signature for Contractor
Printed Name and Title